Case History Form - Audiology
Welcome to RASYA Clinic To provide you better services we request you to fill out these forms to understand your reason to visit and to save waiting time at our clinic.
Do you have history of ear infections or drainage from ear(s)?
Is the hearing loss gradual/sudden (please describe)
If Other, Please Describe
Which ear is more effected with hearing loss / Tinnitus?
If Additional Comments - Please Describe
Do you have difficulty in understanding/ listening ?
If other situations, Please describe.
How important is it to improve how you hear, understand, or communicate with others RIGHT NOW
Previous history of hearing evaluation
Have you had your hearing tested before?
If YES, please provide us details regarding tests (when and where)
Have you experienced any dizziness, balance problems, or falls?
Have you had any pain/discomfort in your ears within the past 90 days ?
If yes to the above question please rate your pain on the scale. (slide the scale)
Do you hear any noises or ringing (tinnitus) in your ears? (If Yes, please answer the next question)
If Yes, is it? (Please describe when did you notice and explain the problem in your own words)
Have you received any medical or surgical treatment for hearing loss?
Do you have trouble with arthritis, stiffness, numbness in your fingers?
History of Hearing Health
Have you ever been exposed to loud noise?
If YES, please describe the type of noise and for how long?
Is there a history of hearing loss in your immediate family?
If YES, How closely are you related?
Medical history & Medication
Any existing medical problems ? (select all that apply, and describe if not mentioned below)
If Others, Please Describe
Please list the medications you are currently using (Drug , Dosage , Frequency)
Do you have history of ear infections?
If you have history of Ear Infections as adult/child, please elaborate.
If Any other, Please elaborate
Have you ever worn a hearing aid(s)?
If YES, please mention type of hearing aid, when it was used
If you used hearing aids earlier, how would you rate your experience with your hearing aid(s) on a scale of 0 (terrible) to 10 (great)?
In what situations, do you think hearing aids would help you more ?
If any other (please describe below)
How confident are you in your own ability to use and take care of hearing aids if they are recommended?
Any comments or questions for audiologists
Submit
